Corporate Compliance

Duplicate gross charges

Compliance Monitor, February 18, 2005

Q: I represent a physician pathology group. Sometimes we bill more than one gross charge on a case. This can happen if several parts were sent. They would be considered one case, but each part would be grossed independently. It can also happen if a case is "regrossed." That is, after reading the microscopic slides, a pathologist may request a case to be regrossed to look for something additional.

In these cases, we find that some managed healthcare companies reject the duplicate gross charge. They will only pay the charge, such as a 88305, that includes the gross, and not pay a 88300 (gross only) along with a 88305.

I have been unable to find something in writing that supports our position and thereby justify that we should be paid for more than one gross fee. Can you help?

A: Based on the question, we are assuming that a single specimen is being examined.

In this case, the physician should select the appropriate code (88300-88309).

CPT 88300 is for a surgical pathology exam, gross examination only; the other CPTs in this range are for surgical pathology exams, gross examination, with microscope.

The CPT selected will be based on the level of work performed. It is not appropriate to bill both 88300 and another CPT in this range if there is only one specimen and one physician (not a second opinion) involved.

This question was answered by Steven Orvis, MPH, senior consultant at Sinaiko Healthcare Consulting, Los Angeles.

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